tag:theconversation.com,2011:/es/topics/liver-transplants-5790/articlesLiver transplants – The Conversation2022-10-14T12:17:26Ztag:theconversation.com,2011:article/1918262022-10-14T12:17:26Z2022-10-14T12:17:26ZHelping the liver regenerate itself could give patients with end-stage liver disease a treatment option besides waiting for a transplant<figure><img src="https://images.theconversation.com/files/489652/original/file-20221013-15-9kim2w.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C2099%2C1426&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Tylenol overdose is one of the leading causes of liver injury requiring liver transplantation.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/illustration/human-purple-liver-wireframe-low-poly-style-royalty-free-illustration/1323289190">Elena Merkulova/iStock via Getty Images</a></span></figcaption></figure><p>The liver is known for its <a href="https://doi.org/10.1038/s41575-020-0342-4">ability to regenerate</a>. It can completely regrow itself even after two-thirds of its mass has been surgically removed. But damage from medications, alcohol abuse or obesity can eventually cause the liver to fail. Currently, the only effective treatment for end-stage liver disease is <a href="https://doi.org/10.1053/j.gastro.2017.01.003">transplantation</a>.</p>
<p>However, there is a <a href="https://doi.org/10.1002/lt.25320">dearth of organs available</a> for transplantation. Patients may have to <a href="https://www.medicalnewstoday.com/articles/states-with-shortest-liver-transplant-waiting-list">wait from 30 days to over five years</a> to receive a liver for transplant in the U.S. Of the <a href="https://www.organdonor.gov/learn/organ-donation-statistics">over 11,600 patients</a> on the waiting list to receive a liver transplant in 2021, only a little over 9,200 received one.</p>
<p>But what if, instead of liver transplantation, there were a drug that could help the liver regenerate itself?</p>
<p>I am the founding director of the <a href="https://livercenter.pitt.edu">Pittsburgh Liver Research Center</a> and run a lab <a href="https://scholar.google.com/citations?user=R2awLBUAAAAJ&hl=en">studying liver regeneration and cancer</a>. In our <a href="https://doi.org/10.1016/j.xcrm.2022.100754">2022 study</a>, my team and I found that activating a particular protein with a new medication can help accelerate regeneration and repair after severe liver injury or partial surgical removal in mice.</p>
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<figcaption><span class="caption">While the liver can regenerate itself, it can’t be endlessly donated for transplants.</span></figcaption>
</figure>
<h2>Key players in liver regeneration</h2>
<p>The liver performs <a href="https://doi.org/10.1126%2Fscitranslmed.3005975">over 500 key functions</a> in your body, <a href="https://www.hopkinsmedicine.org/health/conditions-and-diseases/liver-anatomy-and-functions">including</a> producing proteins that carry fat through the body, converting excess glucose into glycogen for storage and breaking down toxins like ammonia, among others.</p>
<p>Liver cells, or hepatocytes, take on these many tasks by a divide-and-conquer strategy, also called <a href="https://doi.org/10.1016/j.ajpath.2021.09.007">zonation</a>. This separates the liver into three zones with different tasks, and cells are directed to perform specialized functions by turning on specific genes active in each zone. However, exactly what controls the expression of these genes has been poorly understood.</p>
<p>Over the past two decades, my team and other labs have identified one group of 19 proteins called <a href="https://doi.org/10.3727/105221621x16111780348794">Wnts</a> that play an important role in controlling liver function and regeneration. While researchers know that Wnt proteins help activate the repair process in damaged liver cells, which ones actually control zonation and regeneration, as well as their exact location in the liver, have been a mystery.</p>
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<iframe width="440" height="260" src="https://www.youtube.com/embed/o-Kvlxyj43I?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Liver disease progresses in four stages.</span></figcaption>
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<p>To identify these proteins and where they came from, my team and I used a new technology called <a href="https://doi.org/10.1038/s41592-022-01409-2">molecular cartography</a> to identify how strongly and where 100 liver function genes are active. We found that <a href="https://doi.org/10.1016/j.xcrm.2022.100754">only two of 19 Wnt genes</a>, Wnt2 and Wnt9b, were functionally present in the liver. We also found that Wnt2 and Wnt9b were located in the endothelial cells lining the blood vessels in zone 3 of the liver, an area that plays a role in a number of metabolic functions.</p>
<p>To our surprise, eliminating these two Wnt genes resulted in all liver cells expressing only genes typically limited to zone 1, significantly limiting the liver’s overall function. This finding suggests that liver cells experience an ongoing push and pull in gene activation that can modify their functions, and Wnt is the master regulator of this process. </p>
<p>Eliminating the two Wnt genes from endothelial cells also completely stopped liver cell division, and thus regeneration, after partial surgical removal of the liver.</p>
<h2>Liver regeneration after Tylenol overdose</h2>
<p>We then decided to <a href="https://doi.org/10.1016/j.xcrm.2022.100754">test whether a new drug</a> could help recover liver zonation and regeneration. This drug, an antibody called FL6.13, shares similar functions with Wnt proteins, including activating liver regeneration. </p>
<p>Over the course of two days, we gave this drug to mice that were genetically engineered to lack Wnt2 and Wnt9b in their liver endothelial cells. We found that the drug was able to nearly completely recover liver cell division and repair functions.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/489654/original/file-20221013-24-sjaj2m.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Illustration of fatty liver pathology" src="https://images.theconversation.com/files/489654/original/file-20221013-24-sjaj2m.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/489654/original/file-20221013-24-sjaj2m.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/489654/original/file-20221013-24-sjaj2m.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/489654/original/file-20221013-24-sjaj2m.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/489654/original/file-20221013-24-sjaj2m.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/489654/original/file-20221013-24-sjaj2m.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/489654/original/file-20221013-24-sjaj2m.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Left untreated, fatty liver disease can lead to severe damage.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/illustration/fatty-liver-conceptual-illustration-royalty-free-illustration/932736606">Kathryn Kon/Science Photo Library via Getty Images</a></span>
</figcaption>
</figure>
<p>Lastly, we wanted to test how well this drug worked to repair the liver after Tylenol overdose. Tylenol, or acetaminophen, is an over-the-counter medication commonly used to treat fever and pain. However, an overdose of Tylenol can <a href="https://www.ncbi.nlm.nih.gov/books/NBK548162/">cause severe liver damage</a>. Without immediate medical attention, it can lead to liver failure and death. <a href="https://www.ncbi.nlm.nih.gov/books/NBK441917/">Tylenol poisoning</a> is one of the most common causes of severe liver injury requiring liver transplantation in the U.S. Despite this, there is currently only one medication available to treat it, and it is only able to prevent liver damage if taken shortly after overdose.</p>
<p>We tested our new drug on mice with liver damage from toxic doses of Tylenol. We found that one dose was able to decrease liver injury biomarkers – proteins the liver releases when injured – in the blood and reduce liver tissue death. These findings indicate that liver cell repair and tissue regeneration are occurring.</p>
<h2>Reducing the need for transplantation</h2>
<p>One way to address liver transplantation shortages is to improve treatments for liver diseases. While current medications can effectively cure <a href="https://www.who.int/news-room/fact-sheets/detail/hepatitis-c">hepatitis C</a>, a viral infection that causes liver inflammation, other liver diseases haven’t seen the same progress. Because very few effective treatments are available for illnesses like nonalcoholic fatty liver disease and alcoholic liver disease, many patients worsen and end up needing a liver transplant.</p>
<p>My team and I believe that improving the liver’s ability to repair itself could help circumvent the need for transplantation. Further study of drugs that promote liver regeneration may help curb the burden of liver disease worldwide.</p><img src="https://counter.theconversation.com/content/191826/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Satdarshan Monga receives funding from NIDDK and NCI at National Institutes of Health. Satdarshan Monga is a consultant for Surrozen and AntlerA.</span></em></p>Liver transplant waitlists can range from 30 days to over five years. Developing treatments that spur liver regeneration could help reduce demand for scarce organs.Satdarshan (Paul) Singh Monga, Professor of Pathology and Medicine, University of PittsburghLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1510892020-12-07T16:07:02Z2020-12-07T16:07:02ZGenetic engineering transformed stem cells into working mini-livers that extended the life of mice with liver disease<figure><img src="https://images.theconversation.com/files/373147/original/file-20201205-17-veyobm.jpg?ixlib=rb-1.1.0&rect=56%2C155%2C9364%2C9250&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A cross section of lab-grown human liver tissue. The green shows the network of blood vessels.</span> <span class="attribution"><span class="source">Velazquez et al. Cell Systems </span>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span></figcaption></figure><p><strong>Takeaways</strong></p>
<ul>
<li><p><strong>Scientists have made progress growing human liver in the lab.</strong></p></li>
<li><p><strong>The challenge has been to direct stems cells to grow into a mature, functioning adult organ.</strong></p></li>
<li><p><strong>This study shows that stem cells can be programmed, using genetic engineering, to grow from immature cells into mature tissue.</strong></p></li>
<li><p><strong>When a tiny lab-grown liver was transplanted into mice with liver disease, it extended the lives of the sick animals.</strong> </p></li>
</ul>
<hr>
<p>Imagine if researchers could program stem cells, which have the potential to grow into all cell types in the body, so that they could generate an entire human organ. This would allow scientists to manufacture tissues for testing drugs and reduce the demand for transplant organs by having new ones grown directly from a patient’s cells. </p>
<p>I’m a researcher working in this new field – called synthetic biology – focused on creating new biological parts and redesigning existing biological systems. <a href="https://www.cell.com/cell-systems/fulltext/S2405-4712(20)30420-8">In a new paper</a>, my colleagues and I showed progress in one of the key challenges with lab-grown organs – figuring out the genes necessary to produce the variety of mature cells needed to construct a functioning liver.</p>
<p><a href="https://stemcells.nih.gov/info/Regenerative_Medicine/2006Chapter10.htm">Induced pluripotent stem cells</a>, a subgroup of stem cells, are capable of producing cells that can build entire organs in the human body. But they can do this job only if they receive the right quantity of growth signals at the right time from their environment. If this happens, they eventually give rise to different cell types that can assemble and mature in the form of human organs and tissues. </p>
<p>The tissues researchers generate from pluripotent stem cells can provide a unique source for <a href="https://www.fda.gov/drugs/news-events-human-drugs/personalized-medicine-biological-approach-patient-treatment">personalized medicine</a> from transplantation to novel drug discovery. </p>
<p>But unfortunately, synthetic tissues from stem cells are not always suitable for transplant or drug testing because they contain unwanted cells from other tissues, or lack the tissue maturity and a complete network of blood vessels necessary for bringing oxygen and nutrients needed to nurture an organ. That is why having a framework to assess whether these lab-grown cells and tissues are doing their job, and how to make them more like human organs, is critical. </p>
<p>Inspired by this challenge, <a href="https://scholar.google.com/citations?user=C9BfYt0AAAAJ&hl=en">I</a> was determined to establish a <a href="https://ebrc.org/what-is-synbio/">synthetic biology</a> method to read and write, or program, tissue development. I am trying to do this using the genetic language of stem cells, similar to what is used by nature to form human organs. </p>
<h2>Tissues and organs made by genetic designs</h2>
<p>I am a researcher specializing in synthetic biology and biological engineering at the <a href="https://livercenter.pitt.edu">Pittsburgh Liver Research Center</a> and <a href="https://mirm-pitt.net">McGowan Institute for Regenerative Medicine</a>, where the goals are to use engineering approaches to analyze and build novel biological systems and solve human health problems. <a href="https://www.ebrahimkhanilab.com">My lab</a> combines synthetic biology and regenerative medicine in a new field that strives to replace, regrow or repair diseased organs or tissues. </p>
<p>I chose to focus on growing new human livers because this organ is vital for controlling most levels of chemicals – like proteins or sugar – in the blood. The liver also breaks down harmful chemicals and metabolizes many drugs in our body. But the liver tissue is also vulnerable and can be damaged and destroyed by many diseases, such as <a href="https://www.niddk.nih.gov/health-information/liver-disease">hepatitis</a> or <a href="https://www.mayoclinic.org/diseases-conditions/nonalcoholic-fatty-liver-disease/symptoms-causes/syc-20354567">fatty liver disease</a>. There is a shortage of donor organs, which limits liver transplantation.</p>
<p>To make synthetic organs and tissues, scientists need to be able to control stem cells so that they can form into different types of cells, such as liver cells and blood vessel cells. The goal is to mature these stem cells into miniorgans, or <a href="https://www.nature.com/articles/nmeth.4576.pdf?origin=ppub">organoids</a>, containing blood vessels and the correct adult cell types that would be found in a natural organ.</p>
<p>One way to orchestrate maturation of synthetic tissues is to determine the list of genes needed to induce a group of stem cells to grow, mature and evolve into a complete and functioning organ. To derive this list I worked with <a href="http://www.cahanlab.org">Patrick Cahan</a> and <a href="https://www.kianilab.com">Samira Kiani</a> to first use computational analysis to identify genes involved in transforming a group of stem cells into a mature functioning liver. Then our team led by two of my students – Jeremy Velazquez and Ryan LeGraw – used genetic engineering to alter specific genes we had identified and used them to help build and mature human liver tissues from stem cells.</p>
<p>The tissue is grown from a layer of genetically engineered stem cells in a petri dish. The function of genetic programs together with nutrients is to orchestrate formation of liver organoids over the course of 15 to 17 days.</p>
<h2>Liver in a dish</h2>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/373150/original/file-20201205-13-t5uf9l.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/373150/original/file-20201205-13-t5uf9l.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/373150/original/file-20201205-13-t5uf9l.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=205&fit=crop&dpr=1 600w, https://images.theconversation.com/files/373150/original/file-20201205-13-t5uf9l.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=205&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/373150/original/file-20201205-13-t5uf9l.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=205&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/373150/original/file-20201205-13-t5uf9l.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=258&fit=crop&dpr=1 754w, https://images.theconversation.com/files/373150/original/file-20201205-13-t5uf9l.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=258&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/373150/original/file-20201205-13-t5uf9l.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=258&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">The three images, from left to right, show sequential growth of liver tissue on a plate of nutrient rich gel over the course of about 15 days. As the tissue matures, it shrinks, self-organizes and contracts. These livers were then transplanted into mice with liver disease.</span>
<span class="attribution"><span class="source">Velazquez et al. Cell Systems</span>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span>
</figcaption>
</figure>
<p>I and my colleagues first compared the active genes in <a href="https://doi.org/10.1038/ncomms10243">fetal liver organoids</a> we had grown in the lab with those in adult human livers using a computational analysis to get a list of genes needed for driving fetal liver organoids to mature into adult organs. </p>
<p>We then used genetic engineering to tweak genes – and the resulting proteins – that the stem cells needed to mature further toward an adult liver. In the course of about 17 days <a href="https://www.cell.com/cell-systems/fulltext/S2405-4712(20)30420-8">we generated tiny – several millimeters in width – but more mature liver tissues with a range of cells</a> typically found in livers in the third trimester of human pregnancies. </p>
<p>Like a mature human liver, these synthetic livers were able to store, synthesize and metabolize nutrients. Though our lab-grown livers were small, we are hopeful that we can scale them up in the future. While they share many similar features with adult livers, they aren’t perfect and our team still has work to do. For example, we still need to improve the capacity of the liver tissue to metabolize a variety of drugs. We also need to make it safer and more efficacious for eventual application in humans.</p>
<p>[<em>Deep knowledge, daily.</em> <a href="https://theconversation.com/us/newsletters/the-daily-3?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=deepknowledge">Sign up for The Conversation’s newsletter</a>.]</p>
<p>Our study demonstrates the ability of these lab livers to mature and develop a functional network of blood vessels in just two and a half weeks. We believe this approach can pave the path for the manufacture of other organs with vasculature via genetic programming. </p>
<p>The <a href="https://www.cell.com/cell-systems/fulltext/S2405-4712(20)30420-8">liver organoids provide several key features of an adult human liver</a> such as production of key blood proteins and regulation of bile – a chemical important for digestion of food.</p>
<p>When we implanted the lab-grown liver tissues into mice suffering from liver disease, it increased the life span. We named our organoids “designer organoids,” as they are generated via a genetic design.</p><img src="https://counter.theconversation.com/content/151089/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Mo Ebrahimkhani receives funding from National Institute of Health, University of Pittsburgh and Arizona Biomedical Research Council.</span></em></p>New strategy helps build synthetic organs from scratch. This enabled the researchers to grow functioning liver tissue in the lab that could be transplanted into mice with liver disease.Mo Ebrahimkhani, Associate Professor of Pathology and Bioengineering, University of PittsburghLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1450882020-09-09T21:23:40Z2020-09-09T21:23:40ZAn opt-out organ donor system could address Canada’s shortage of organs for transplant<figure><img src="https://images.theconversation.com/files/357316/original/file-20200909-24-1r85pz3.jpg?ixlib=rb-1.1.0&rect=498%2C188%2C4430%2C3175&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Eighty-five per cent of Ontarians support organ donation, but only one-third have opted in under the current system.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>In 2018, there were <a href="https://www.cihi.ca/en/organ-replacement-in-canada-corr-annual-statistics-2019#:%7E:text=At%20the%20end%20of%202018,while%20waiting%20for%20a%20transplant">4,351 Canadians on waiting lists</a> for an organ transplant. In the same year, 223 Canadians died while awaiting organ transplants. </p>
<p>These numbers have been growing over the last decade. For example, between 2009 and 2019, the number of <a href="https://www.cihi.ca/sites/default/files/document/corr-snapshot-2019-en.pdf">Canadians in end-stage renal failure increased by 35 per cent</a>, significantly raising the number of individuals requiring kidney transplants. The situation is only expected to worsen, as it is anticipated that <a href="https://doi.org/10.1186/s12882-017-0699-y">more Canadians will require organ transplants over the coming years</a>.</p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/356502/original/file-20200904-16-9nqn3j.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Cross-sectional illustration of a human kidney" src="https://images.theconversation.com/files/356502/original/file-20200904-16-9nqn3j.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/356502/original/file-20200904-16-9nqn3j.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=911&fit=crop&dpr=1 600w, https://images.theconversation.com/files/356502/original/file-20200904-16-9nqn3j.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=911&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/356502/original/file-20200904-16-9nqn3j.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=911&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/356502/original/file-20200904-16-9nqn3j.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1144&fit=crop&dpr=1 754w, https://images.theconversation.com/files/356502/original/file-20200904-16-9nqn3j.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1144&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/356502/original/file-20200904-16-9nqn3j.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1144&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">End-stage kidney disease increased by more than 35 per cent in Canada between 2009 and 2019.</span>
<span class="attribution"><span class="source">(Pixabay)</span></span>
</figcaption>
</figure>
<p>In the backdrop of these sobering statistics, Nova Scotia is set to become the first jurisdiction in North America to enact legislation to tackle the shortage of organs for transplant. Passed on April 2, 2019, the <a href="https://nslegislature.ca/legc/bills/63rd_2nd/1st_read/b133.htm">Human Organ and Tissue Act</a> is scheduled to come into effect on Jan. 18, 2021. </p>
<p>The act institutes an “opt-out” system to organ donation, which functions on the idea of presumed consent. In its essence, this idea presumes that individuals have consented to having their organs harvested upon their death for transplantation into others in need of those organs. </p>
<p>Nova Scotia’s opt-out system goes against prevailing practice in Canada. Currently, organ donation is based on the “opt-in” system, in which individuals must sign up to be organ donors while they are alive in order for their organs to be harvested for transplantation upon their death.</p>
<h2>The case for presumed consent</h2>
<p>There is ample evidence to substantiate the effectiveness of presumed consent policy. Take the case of Spain, the country with the most robust opt-out system, which it established over 40 years ago. In 2019, <a href="https://www.healio.com/news/nephrology/20200605/presumed-consent-helpful-for-increasing-transplants-in-spain-but-challenges-remain">Spain had 49 deceased organ donors per million population</a> — by far the highest in the world. This compares to Canada’s paltry rate of 20.6 per million population on the same measure.</p>
<p>Despite Canada’s lagging donation indicators, most Canadians support organ donation. For example, <a href="https://www.giftoflife.on.ca/en/">85 per cent of Ontarians support donation</a>, although only one-third have opted-in to the current system. </p>
<p>This discrepancy has been attributed to apathy in registering as a donor rather than <a href="https://dx.doi.org/10.1177%2F1751143718777171">serious moral objections to donating posthumously</a>. If surveys of public opinion are correct, then an opt-out system would get it right more times than it gets it wrong when making assumptions about individuals’ wishes. </p>
<h2>Moral objections</h2>
<p>Those who object to organ donation for religious or other reasons are more likely to make their wishes known in an opt-out system as compared to those wishing to donate for altruistic reasons, who are <a href="https://doi.org/10.1076/jmep.29.1.37.30412">less likely to make their preferences clear in an opt-in system</a>. </p>
<p>In a system designed to save more lives, putting the onus on those who object to donation to opt-out is not only morally justified, but follows other initiatives in which public interest is placed at the forefront of policy. For instance, the introduction of mandatory seat-belt laws have often come under fire for infringing on individual autonomy, but the prevailing benefit to public interest has resulted in a now <a href="https://doi.org/10.1093/phe/phz014">widely accepted legal and social norm</a>. </p>
<figure class="align-center ">
<img alt="Illustration of kidneys, heart, lungs and liver with a green ribbon, symbol for organ donation support" src="https://images.theconversation.com/files/356585/original/file-20200904-18-1gi4d07.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/356585/original/file-20200904-18-1gi4d07.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=140&fit=crop&dpr=1 600w, https://images.theconversation.com/files/356585/original/file-20200904-18-1gi4d07.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=140&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/356585/original/file-20200904-18-1gi4d07.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=140&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/356585/original/file-20200904-18-1gi4d07.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=176&fit=crop&dpr=1 754w, https://images.theconversation.com/files/356585/original/file-20200904-18-1gi4d07.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=176&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/356585/original/file-20200904-18-1gi4d07.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=176&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Eighty-five per cent of Ontarians support organ donation, but only one-third have opted in to the current system.</span>
<span class="attribution"><span class="source">(Canva)</span></span>
</figcaption>
</figure>
<p>Policy debates over whether a jurisdiction ought to have an opt-out versus on opt-in system to organ transplantation are replete with thorny ethical questions. There are usually no simple, clear-cut answers and not all members of the public will be satisfied with any decision reached. </p>
<p>But given the number of Canadians detrimentally affected by types of organ failure that can be medically remedied through transplantation, the country has an ethical responsibility to consider how best to approach the ongoing shortage of donor organs.</p>
<h2>Lowering costs while saving lives</h2>
<p>Beyond the moral reasons for instituting an opt-out system, there are financial incentives too. For example, where it concerns end-stage renal failure, the British Columbia Renal Agency found that the <a href="http://www.bcrenalagency.ca/resource-gallery/Documents/Transplant%20and%20recipient%20eligibility.pdf">annual cost of dialysis treatment is $50,000 per person</a>. This is meaningfully higher than the cost of kidney transplantation, which has a <a href="http://www.bcrenalagency.ca/resource-gallery/Documents/Transplant%20and%20recipient%20eligibility.pdf">one-time associated price tag of $15,000 and $5,500 per year for anti-rejection drugs</a>. </p>
<p>To be sure, it would be wholly unreasonable to expect Nova Scotia’s new act to be implemented without any hiccups. There will likely be unforeseen, complex and difficult issues that emerge as the province begins to put the act into operation in the coming weeks. Moreover, as evidence from jurisdictions that have established presumed consent policy reveals, the effects of the opt-out policy are tenuous unless <a href="https://doi.org/10.3399/bjgp18X694445">sufficient financial and political support buttress it</a>. </p>
<p>While there may be challenges, instituting policy on organ harvesting based on presumed consent could be an important initial step in addressing the ever-growing shortage of organ donors in the country. Other provinces in Canada ought to pay close attention to the forthcoming experiment in Nova Scotia, and consider how their own jurisdictions might respond to the shortage of organ donors — a phenomenon that is causing many avoidable deaths and much unnecessary suffering to Canadians.</p>
<p><em>This is a corrected version of a story originally published Sept. 9, 2020. The earlier story incorrectly stated that the opt-out program would take effect on Oct. 1, 2020.</em></p><img src="https://counter.theconversation.com/content/145088/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Ajnesh Prasad receives funding from the Social Sciences and Humanities Research Council and the Canada Research Chairs program. </span></em></p><p class="fine-print"><em><span>Karly Nygaard-Petersen does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Thousands of Canadians are on waiting lists for life-saving organ transplants. An opt-out organ donor system, like the one Nova Scotia is implementing, could reduce avoidable deaths and suffering.Ajnesh Prasad, Professor & Canada Research Chair, School of Business, Royal Roads UniversityKarly Nygaard-Petersen, Doctoral student, School of Business, Royal Roads UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1325962020-03-09T19:01:01Z2020-03-09T19:01:01ZWild Butterfly film review: Claire Murray’s story gives a human face to trauma, drug use and blame culture<figure><img src="https://images.theconversation.com/files/318792/original/file-20200305-127951-37x764.jpg?ixlib=rb-1.1.0&rect=20%2C5%2C1973%2C1137&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Wild Butterfly/FanForce</span></span></figcaption></figure><p>Who deserves our compassion and medical care? Does a person who has used drugs deserve a liver transplant … and then a second? What if she’s 24 years old and a mother of small children? What if she had been prescribed the drugs initially for a mental health condition? What if she started showing mental-health symptoms after she was sexually assaulted and then mercilessly bullied? Would she be more deserving then?</p>
<p>These are some of the questions raised by <a href="https://fan-force.com/films/wild-butterfly/">Wild butterfly</a>, the story of Claire Murray, who died in 2010 at just 24 years old after complications from a <a href="https://www.perthnow.com.au/news/wa/liver-mum-claire-murray-reveals-i-dont-deserve-a-second-chance-ng-6753f9d062c04f37fb0f43ed4347004d">failed liver transplant</a>. Her search for a second liver was the subject of <a href="https://www.theaustralian.com.au/news/nation/claire-murrays-family-to-sell-home-to-pay-500000-liver-transplant-debt/news-story/5a0e6bdbf49da5ab73961313a53a6dd6">scathing media coverage</a>. “They had a poll on her life,” Claire’s mother says in the documentary. “[It asked] ‘Do you think she deserves to live or die?’” </p>
<p>The documentary also raises questions about how she was treated by some health professionals and the general public on social media, treatment that was underpinned by prejudice about people who use drugs and a lack of understanding about problematic use and relapse.</p>
<p>More broadly, it’s also a story of stigma and discrimination and a reminder of what can happen when the media mine trauma and drug use for clickbait.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/JsZ58j_2PNA?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Wild Butterfly is billed as a true crime documentary, but gives insights into the stigma faced by drug users and their families.</span></figcaption>
</figure>
<h2>More to the story</h2>
<p>Claire was subjected to trial by media, portrayed as an ungrateful “junkie” who wantonly wasted her first transplant opportunity. <a href="https://www.perthnow.com.au/news/wa/liver-mum-claire-murray-reveals-i-dont-deserve-a-second-chance-ng-6753f9d062c04f37fb0f43ed4347004d">Reports from the time</a> said Claire “admitted taking drugs after the first transplant” and was prevented from returning to the transplant waiting list by rules “that forbid persistent substance abusers from being eligible for donor organs”. In fact, the film tells us she had a rare clotting disorder that led to the rejection of her first liver.</p>
<p>The film describes how she was sexually assaulted at 12 years old while on a camp, and then subjected to unrelenting bullying and stalking, which led her down a path of drug use.</p>
<p>Exposure to trauma in childhood is <a href="https://dx.doi.org/10.1097%2FHRP.0000000000000014">linked</a> to a range of psychological, social, developmental and medical problems right through to adulthood. </p>
<p>We now know <a href="https://developingchild.harvard.edu/science/key-concepts/toxic-stress/">neglect and abuse</a> in childhood permanently rewires the developing brain. <a href="https://dx.doi.org/10.1097%2FHRP.0000000000000014">Emotional dysregulation</a> is the primary feature among people who have experienced trauma, and many people turn to alcohol or other drugs to help regulate these negative, often unbearable, emotions.</p>
<p>A large percentage of people who have experienced physical, sexual or other abuse as children or adults <a href="https://www.google.com/search?client=safari&rls=en&q=trauma+and+drug+use+epidemiliolgy&ie=UTF-8&oe=UTF-8">use alcohol and other drugs</a> to try to dampen the constant feelings of fear, anxiety and depression; and a large proportion of people <a href="https://www.google.com/search?client=safari&rls=en&q=trauma+among+people+in+drug+treatment&ie=UTF-8&oe=UTF-8">in treatment</a> for alcohol or other drug problems have a history of abuse.</p>
<p>We can never know someone’s circumstances or their motivations. Wild Butterfly is a sad reminder of how much additional damage can be done by people making assumptions and judging those who use drugs.</p>
<h2>Blame culture</h2>
<p>This film balances the sensitive and nuanced issues without doing further harm. It explains the issues of drug use and trauma, without laying blame on people who use drugs or their families – and it does it with humanity. In my view, this sense of empathy and humanity is too often absent from mainstream reporting on people who experience problems with alcohol and other drugs.</p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/318795/original/file-20200305-127877-5ns3v7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/318795/original/file-20200305-127877-5ns3v7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/318795/original/file-20200305-127877-5ns3v7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=800&fit=crop&dpr=1 600w, https://images.theconversation.com/files/318795/original/file-20200305-127877-5ns3v7.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=800&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/318795/original/file-20200305-127877-5ns3v7.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=800&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/318795/original/file-20200305-127877-5ns3v7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1005&fit=crop&dpr=1 754w, https://images.theconversation.com/files/318795/original/file-20200305-127877-5ns3v7.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1005&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/318795/original/file-20200305-127877-5ns3v7.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1005&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">The public didn’t know that abuse and bullying played a role in Claire’s drug use.</span>
<span class="attribution"><span class="source">Wild Butterfly/FanForce</span></span>
</figcaption>
</figure>
<p>Wild Butterfly tells the story of Claire largely from her parents’ point of view. It was her dying wish to set the record straight. You can feel their pain and it’s heartbreaking. What if it was your child? What would you do to ensure they had a chance at recovery? The parents’ story also demonstrates that families of people with alcohol and other drug problems need support.</p>
<p>It’s the people who judge others on their drug use who really need to watch this film and, sadly, they probably won’t. The film is a reminder that there’s more to people and their circumstances than meets the eye.</p>
<p>There are opportunities for reflection on the part of the media, the health profession and the general community. There are media guidelines on reporting on drug and mental health issues available from <a href="https://www.aodmediawatch.com.au/guidelines-for-journalists/">AOD Media Watch</a> and <a href="https://mindframe.org.au/alcohol-other-drugs/communicating-about-alcohol-other-drugs">Mindframe</a>.</p>
<p>We have come a long way in our understanding about other common mental-health disorders, like depression and anxiety, but we still have a long way to go when it comes to empathy and compassion for people who use alcohol and other drugs.</p>
<p><em>If you need information or support, contact the National Alcohol and Other Drug Hotline on 1800 250 015.</em></p>
<p><em><a href="https://fan-force.com/films/wild-butterfly/">Wild Butterly</a> is screening in cinemas nationally.</em></p><img src="https://counter.theconversation.com/content/132596/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Nicole Lee works as a consultant in the alcohol and other drug sector and a psychologist in private practice. She has previously been awarded funding by Australian and state governments, NHMRC and other bodies for evaluation and research into drug prevention and treatment. She is a member of board of directors of Hello Sunday Morning.</span></em></p>New Australian film Wild Butterfly is a story of stigma and discrimination directed towards people who use drugs. And a reminder of what can happen when trauma and drug use are played for click bait.Nicole Lee, Professor at the National Drug Research Institute (Melbourne), Curtin UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1150512019-05-01T23:26:26Z2019-05-01T23:26:26ZA little nudge goes a long way in increasing organ donor registrations<figure><img src="https://images.theconversation.com/files/271242/original/file-20190427-194612-q62rkj.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C3000%2C2182&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A Nova Scotia woman displays the tattoo that marks her two liver transplants at the provincial legislature in Halifax in April 2019. The province's Human Organ and Tissue Donation Act will allow Nova Scotians to donate their organs and tissue unless they opt out.</span> <span class="attribution"><span class="source">THE CANADIAN PRESS/Andrew Vaughan</span></span></figcaption></figure><p>Each year, hundreds of Canadians die waiting for organ transplants. <a href="https://blood.ca/en/news-and-events/newsroom/system-progress-data-show-continued-improvement-in-deceased-organ-donation-rates">At the end of 2017, for example, 4,333 people were waiting for transplants; 242 of them died.</a></p>
<p>Many of these deaths could be prevented if people signed their organ donor registration cards. And even though the vast majority of <a href="https://organtissuedonation.ca/en/about">Canadians support organ donation, less than 23 per cent have made plans to donate.</a></p>
<p>With <a href="https://www.beadonor.ca/about-donation">one organ donor having the potential to benefit more than 75 people and save up to eight lives</a>, is there a way to encourage more people to sign an organ donor card? Our research reveals there is.</p>
<p>Behavioural science tells us that there are some key psychological barriers that prevent people from becoming organ donors, including what’s known as the <a href="https://science.sciencemag.org/content/302/5649/1338">status quo bias</a> — meaning we tend to stick with the status quo, or current state of affairs, even when making a change would better align with our personal beliefs and goals.</p>
<p>Developing interventions to overcome these barriers has the potential to close the gap between the <a href="https://www.ipsos.com/en-ca/most-canadians-81-willing-donate-their-organs-case-their-death">81 per cent of Canadians who indicate they’re willing to donate their organs after death</a> and the mere 23 per cent who are registered.</p>
<p>In fact, during an eight-week trial conducted with the Ontario government at one Service Ontario centre, <a href="https://www.ontario.ca/page/behavioural-insights-pilot-project-organ-donor-registration">such interventions led to a dramatic increase in organ donor registrations</a>.</p>
<h2>Nudging people into action</h2>
<p>Those who haven’t given the idea much thought are sometimes caught off guard by the question of whether they want to donate their organs after death. And when people are asked to make a decision that they don’t feel they’ve put adequate time and effort into considering, they choose not to decide. They put it off. </p>
<p>In many jurisdictions, the decision to donate organs happens most often when people renew their driver’s licences or health cards. <a href="https://www.ontario.ca/page/behavioural-insights-pilot-project-organ-donor-registration">In Ontario, for example, 85 per cent of organ donor registrations occur at Service Ontario centres via a prompted-consent system.</a> Customer service representatives ask if people are willing to register to be an organ donor.</p>
<figure class="align-left zoomable">
<a href="https://images.theconversation.com/files/271244/original/file-20190427-194612-1x8883q.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/271244/original/file-20190427-194612-1x8883q.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/271244/original/file-20190427-194612-1x8883q.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/271244/original/file-20190427-194612-1x8883q.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/271244/original/file-20190427-194612-1x8883q.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/271244/original/file-20190427-194612-1x8883q.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/271244/original/file-20190427-194612-1x8883q.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/271244/original/file-20190427-194612-1x8883q.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">A kidney transporter provides a sealed, sterile environment while the organ is being preserved outside the body.</span>
<span class="attribution"><span class="source">Trillium Gift of Life Network</span></span>
</figcaption>
</figure>
<p>To improve the process at Service Ontario centres and avoid surprising people with the question, a number of interventions were tested, from simplifying the organ donor registration form to providing the form earlier in the process and giving key information at optimal points in time. </p>
<p>Another change: At the top of each consent form, several statements in bold text were tested: “If you needed a transplant, would you have one?” And: “How would you feel if you or someone you loved needed a transplant and couldn’t get one?” </p>
<p>Such “nudge” statements are designed to motivate people to take action while maintaining their freedom of choice. These nudge statements helped people imagine themselves in the position of someone needing a transplant.</p>
<p><a href="https://www.ontario.ca/page/behavioural-insights-pilot-project-organ-donor-registration">The most successful changes from this Ontario pilot project led to a 143 per cent increase in organ donor registrations</a>. If rates were to rise similarly across the province, the Ontario government estimates it could increase organ donor registrants by more than 450,000 a year — up from the current number of approximately 200,000.</p>
<h2>The drawbacks of presumed consent</h2>
<p>Additional methods of increasing organ donor registrations have also been investigated in some jurisdictions. Presumed consent is one example — a system whereby individuals are automatically registered as donors unless they explicitly opt out.</p>
<hr>
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<strong>
Read more:
<a href="https://theconversation.com/organ-donation-does-presumed-consent-work-49478">Organ donation: does presumed consent work?</a>
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<p>In April, <a href="https://atlantic.ctvnews.ca/nova-scotia-legislature-passes-presumed-consent-law-for-organ-donation-1.4378612">Nova Scotia became the first jurisdiction in North America to adopt presumed consent for organ donations.</a></p>
<p>While there’s been some indication that <a href="https://science.sciencemag.org/content/302/5649/1338">countries with presumed consent have 60 per cent more of the population registered</a>, there is also evidence that it may be ineffective. <a href="https://www.sciencedirect.com/science/article/pii/S0041134513000390?via%3Dihub">Chile saw a decrease in organ donations when it implemented the system</a>, <a href="https://www.bbc.com/news/health-41199918">as did France and Brazil.</a></p>
<p>Part of the reason for the decline is that families have the last word. When you make the decision to become an organ donor, often your family is aware of your intent. But when the government assumes you want to donate your organs without your explicit consent, your family may overturn the decision after your death.</p>
<p>For these reasons it will be interesting to see the impact of Nova Scotia’s decision. </p>
<p>Meanwhile in Ontario, many of the insights uncovered by the pilot project conducted with Ontario’s Behavioural Insights Unit —including the nudge statements — are now used on <a href="http://www.forms.ssb.gov.on.ca/mbs/ssb/forms/ssbforms.nsf/GetFileAttach/014-3750-84%7E1/%24File/ATTFCBXW.pdf">Ontario’s organ and tissue donor registration consent form</a>, and data is being collected to determine how things have improved.</p>
<p>It’s a great example of how the government is using evidence-based decision-making to better serve its citizens, and how research into consumer behaviour can benefit society.</p>
<hr>
<p><em>Nicole Robitaille conducted this research with Nina Mazar, Claire Tsai and Elizabeth Hardy in partnership with the the Ontario Government’s Behavioural Insights Unit and the Behavioural Economics in Action research centre at the Rotman School of Management (BEAR).</em></p><img src="https://counter.theconversation.com/content/115051/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>In addition to her academic work, Nicole currently serves as a Trusted Advisor and Advisory Committee Member to the Government of Canada’s Impact and Innovation Unit. She also currently serves as an Advisor to the Ontario Government’s Behavioural Insights Unit (Treasury Board), where she formally worked as Chief Researcher.
</span></em></p>Most Canadians support organ donation after death, but fewer than 25 per cent have registered to donate their organs. What can be done to encourage more registrations?Nicole Robitaille, Assistant Professor of Marketing, Queen's University, OntarioLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1073882018-11-28T12:57:31Z2018-11-28T12:57:31ZLiver transplant from HIV+ living donor to negative recipient: the unanswered questions<figure><img src="https://images.theconversation.com/files/247683/original/file-20181128-32230-1q19ef7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">More than a year after a groundbreaking liver transplant doctors still can't say if the recipient is HIV-positive or not.</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>A lifesaving partial liver transplant from an HIV-infected mother to her uninfected child – the first of its kind – was conducted last year at the University of the Witwatersrand’s <a href="http://www.dgmc.co.za/">Donald Gordon Medical Centre</a> in Johannesburg. More than a year later, both mother and child are doing well. </p>
<p>But the crucial question of the child’s HIV infection status remains unanswered. And we don’t expect to have a definitive answer any time soon.</p>
<p>Despite this uncertainty, the story of the transplant is inspiring. To date there have been no published reports of a living organ donation by a person with HIV, or of an intentional transplant from an HIV-positive to HIV-negative individual. The operation was driven by a number of factors. These included life-threatening liver failure in the child, no available deceased or suitable live HIV-uninfected donors, and an HIV-positive mother’s continued pleas to be allowed to save her child.</p>
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Read more:
<a href="https://theconversation.com/liver-transplant-from-hiv-living-donor-to-negative-recipient-key-ethical-issues-104010">Liver transplant from HIV+ living donor to negative recipient: key ethical issues</a>
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<p>We’ve learned a great deal from the operation and during the subsequent year. Most importantly, the success of this transplant provides a new therapeutic option for similar cases in high burden HIV countries where deceased donor organs are limited in number, or where access is limited. </p>
<p>But there are still gaps in our knowledge. The biggest is what the long term effect of the transplant will be on the child, and particularly whether the mother’s virus was transferred with the liver.</p>
<h2>The journey</h2>
<p>The child was 13 months old when the transplant happened. The liver has a remarkable ability to regenerate and grows back to its normal size in the donor in about six weeks.</p>
<p>Although born to an HIV-positive mother, the child did not have HIV. The mother was on antiretroviral therapy during pregnancy, and the child received standard preventative treatment. </p>
<p>The mom had an undetectable virus ahead of the transplant. The child also received antiretrovirals ahead of the transplant to try and prevent infection. Both mom and child are still on HIV treatment today. The child is also on immunosuppressive therapy to prevent liver rejection.</p>
<p>After the transplant, the child was tested for HIV. No virus was detected. Very sensitive tests also couldn’t detect traces of the virus within cells. This means that, one year on, there is no direct evidence of virus in the blood or blood cells. </p>
<p>But there is a caveat. Just because we can’t detect the virus doesn’t mean it isn’t hiding in very small amounts.</p>
<p>There’s another reason we can’t conclusively say whether the child is infected or not: 43 days after the operation HIV antibodies were detected in the child using standard diagnostic tests. But these antibodies have since decreased in amount. Normally, the presence of HIV antibodies means a person has been infected. But in this case, we can’t tell if these antibodies belong to the child or the mother (or both) because of the donor cells in the liver. </p>
<p>Because of these uncertainties, treatment is being continued for the moment. Whether this will be lifelong remains one of many open and unanswered questions.</p>
<h2>Unanswered questions</h2>
<p>The operation, and subsequent events, have put us on the cusp of new insights and understanding about HIV and its transmission.</p>
<p>We’ve been able to get some insights from previous events. For example, the transfer of <a href="https://aasldpubs.onlinelibrary.wiley.com/doi/epdf/10.1002/lt.21534">HIV through liver transplantation</a> has accidentally happened where deceased donors unknowingly had HIV. In all cases there was clear evidence of HIV infection in the recipient. </p>
<p>There are lots of other examples – not HIV related – of the transfer of specific immune responses from a donor to the recipient. An interesting one is the transfer of an <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5716392/pdf/jaa-10-307.pdf">allergic reaction to peanuts</a> in cases where the recipients had no prior history of peanut allergy but developed reactions following transplantation. Such transfer of donor immune responses is why we can’t use our standard HIV antibody tests for a conclusive diagnosis of recipient HIV infection in the setting of transplantation.</p>
<p>Two factors make the situation we find ourselves in unique: it’s the first time that liver tissue from an HIV positive living person has been transplanted to a HIV-negative person. The second is that the liver is very different to other organs. </p>
<p>The liver is the major draining organ for substances passing through the gut. Because of its role in metabolism, nutrient storage and detoxification it needs to distinguish foreign particles that are good (food) from those that are bad (pathogens). That’s what makes it immunologically tolerant. Tolerance means the immune system is geared to prevent an overreaction to good molecules. </p>
<p>It’s not known how this tolerance might affect the risk of HIV infection. <a href="https://ac.els-cdn.com/S0042682213004467/1-s2.0-S0042682213004467-main.pdf?_tid=e43f8179-6c5c-4179-b987-73993a086539&acdnat=1543316015_bbbc31f6c2e624b1937f3ad5276edd61">Studies</a> on monkeys have shown an absence of actively infected cells in the liver compared with other organs. The presence of antiretrovirals in our transplant mom-child case would make the presence of actively infected cells even less likely. </p>
<p>On the other hand, latent or “silently” infected cells which are very difficult to detect could be present in small numbers and pose a potential risk of sparking an infection if antiretroviral treatment were ever stopped.</p>
<h2>The way forward</h2>
<p>There are still many gaps in our knowledge. For example, we need to understand HIV in the liver of patients who are on antiretrovirals and virally suppressed. </p>
<p>We also need to have a better understanding of this novel type of HIV exposure so that we can inform best practice in the setting of HIV-positive donor liver transplants. </p>
<p>Studies of this case and of further transplants of this nature will help us to fill in these knowledge gaps. </p>
<p>The ultimate aim is to have the best of both worlds – a life-saving intervention together with successful prevention of HIV infection in the transplant recipient.</p><img src="https://counter.theconversation.com/content/107388/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Caroline T. Tiemessen receives research funding from the South African Medical Research Council (MRC) Strategic Health Innovation Partnerships (SHIP) programme, Department of Science and Technology/National Research Foundation (DST/NRF) South Africans Chair Initiative (SARChI) programme, Poliomyelitis Research Foundation (PRF), and the US National Institutes of Health (NIH).</span></em></p>A liver transplant from an HIV-positive living donor to an HIV-negative recipient is possible, but there are still gaps in our knowledge.Caroline T. Tiemessen, Head: Cell Biology, Centre for HIV and STIs, National Institute for Communicable DiseasesLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/921952018-03-07T12:21:26Z2018-03-07T12:21:26ZLiving (and competing) after an organ transplant<figure><img src="https://images.theconversation.com/files/207279/original/file-20180221-132677-1x6ygxb.png?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Running on a transplanted liver.</span> <span class="attribution"><span class="source">Gareth Wiltshire</span>, <span class="license">Author provided</span></span></figcaption></figure><p>Organ donations <a href="http://www.bbc.co.uk/news/health-43060382">continue to rise</a> and a growing number of countries are adopting <a href="https://www.theguardian.com/society/2017/jan/02/france-organ-donation-law">assumed consent donation policies</a>. These recent shifts can partially be explained by increasing public awareness that <a href="https://www.organdonation.nhs.uk/supporting-my-decision/statistics-about-organ-donation/">organ donation saves lives</a>. </p>
<p>But it is important to understand that life for people receiving an organ transplant will never be the same. The experience of being a transplant recipient involves managing ongoing medical treatment, an uncertainty about future illness and a complex <a href="http://journals.sagepub.com/doi/abs/10.1177/1049732314553853">emotional relationship with one’s donor</a> – living or deceased. </p>
<p>With a growing number of transplant recipients using <a href="http://www.transplantsport.org.uk/how-we-began">sport and exercise</a> as a means to maintain health and well-being following their transplant, <a href="http://garethwiltshire.wixsite.com/research/transplant">our research</a> is revealing for the first time how sport can play a crucial role in the lives of transplant recipients as they deal with the realities of their health being reliant on someone else’s organ.</p>
<p>For many transplant recipients, especially those requiring kidneys, transplantation is seen as a treatment rather than a cure for illness. This means that patients may rely on organ donation multiple times throughout their life, making them especially aware of the need to take responsibility for looking after their own health. </p>
<p>One participant with a transplanted liver in our study told us: </p>
<blockquote>
<p>I’m always conscious that I’ve got somebody’s organ in me. I always give it a little tap [to say] ‘Are you okay in there? Have I been good to you today?’</p>
</blockquote>
<p>Many transplant recipients see sport and exercise as a key way to maintain their health and to keep their transplanted organ as functional as possible. Participating in physical activities allows patients to work towards sustaining their own health. Importantly, this self-care is also experienced with a sense of gratitude and duty towards one’s donor and donor family. As another interviewee put it:</p>
<blockquote>
<p>Somebody has donated those organs, and because of that person you are alive. So you sort of owe it to them.</p>
</blockquote>
<p>Transplant recipients can also see sport and exercise as a way of redefining themselves. After being on a transplant waiting list for months or sometimes years, people may have difficulty in the shift from seeing themselves as being ill to being healthy again. </p>
<p>Sport and exercise can be a way of exploring new physical capabilities and rediscovering old ones. One man whose cystic fibrosis had affected his breathing since childhood commented: </p>
<blockquote>
<p>I wanted to show off my new lungs. Wouldn’t it be amazing to do something cardio-vascular? So I thought, why don’t I join an athletics club and see where that takes me.</p>
</blockquote>
<p>Indeed, sport and exercise provide tangible milestones for new transplant recipients. They serve as a benchmark of health status, provide motivational goals and allow opportunities to celebrate survival. </p>
<figure>
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</figure>
<p>Around the world, there are now opportunities to compete against other transplant recipients in events such as the <a href="https://australiantransplantgames.com/">Australian Transplant Games</a>, the <a href="https://www.vantaa2016.fi/en/vantaa2016/games/ehltc">European Heart and Lung Transplant Championships</a> and even the <a href="https://wtgf.org/">World Transplant Games</a> which takes place every two years. These events have the value of providing rare and important opportunities to build social relationships with other transplant recipients. </p>
<h2>This sporting life</h2>
<p>After what are often isolating illness experiences, social relationships at these events provide participants with emotional support, health advice and knowledge about what to expect in the future. In the words of one competitor: </p>
<blockquote>
<p>It’s good to see that thousands of other people are going through the same thing, and successfully. It gives you hope that you can keep going and keep living for as long possible.“</p>
</blockquote>
<p>Of course, increased social reach has a less positive effect when participants learn of the ill health or death of friends and teammates. When this happens, one transplant recipient said: </p>
<blockquote>
<p>I guess maybe I have an underlying fear that maybe my liver disease will come back one day. I’m not expecting in any way that it will, but it gets you thinking about it a bit. It is a healthy reminder that it’s not all plain sailing.</p>
</blockquote>
<p>Plain sailing it isn’t. But newly transplanted patients and their medical teams should be aware of opportunities to participate in sport and exercise and the ways in which this can affect their experience of illness.</p>
<p>For anyone registered as an organ donor, this illuminating research may also demonstrate how transplant recipients so often do make the most of the "gift of life” – when they are lucky enough to receive it.</p><img src="https://counter.theconversation.com/content/92195/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Gareth Wiltshire is affiliated with the Transplant Sport UK charity as a volunteer coach. </span></em></p>Sport can provide organ recipients with motivation and a chance to celebrate.Gareth Wiltshire, Lecturer, University of BathLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/780412017-06-18T19:53:14Z2017-06-18T19:53:14ZA quarter of kidney donors are living: what you need to know to be a donor<figure><img src="https://images.theconversation.com/files/172669/original/file-20170607-11330-15z6fwj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">People undergoing dialysis would have a better quality of life if they had a kidney transplant.</span> <span class="attribution"><span class="source">from shutterstock.com</span></span></figcaption></figure><p>At any one time, <a href="http://www.donatelife.gov.au/sites/default/files/Facts%20and%20Stats%20Fact%20Sheet%20-Feb%202017.pdf">more than 1,400 Australians</a> are on an organ transplant waiting list. The most common organs in demand are kidneys, followed by the liver and lung. </p>
<p>While the number of deceased organ donors in Australia has <a href="http://www.donatelife.gov.au/sites/default/files/Australian%20Donation%20and%20Transplantation%20Activity%20Report%202016.pdf">doubled since 2009</a>, rates of live donor transplantation – where a person donates one kidney or, rarely, a portion of their liver – are relatively static.</p>
<p>In 2016, 265 Australians <a href="http://www.donatelife.gov.au/sites/default/files/OTA%20Factsheet%20-%20Living%20Donation%20and%20AKX_05%20V2.pdf">donated a kidney</a> to a friend or relative, making up about a quarter of all kidney transplants. Live donor liver transplants are rare (only two occurred in Australia last year) and often donated from a parent to a child.</p>
<iframe src="https://datawrapper.dwcdn.net/DbcyM/2/" scrolling="no" frameborder="0" allowtransparency="true" allowfullscreen="allowfullscreen" webkitallowfullscreen="webkitallowfullscreen" mozallowfullscreen="mozallowfullscreen" oallowfullscreen="oallowfullscreen" msallowfullscreen="msallowfullscreen" width="100%" height="403"></iframe>
<h2>Who needs a kidney?</h2>
<p>Kidneys filter toxins from the blood and regulate fluid balance. When kidneys are functioning so poorly a person needs dialysis to do the work for them, we say the person has “end stage kidney disease”. </p>
<p>In 2015, there were <a href="http://www.anzdata.org.au/brochures/brochure_2016v4.0_20170102.pdf">nearly 12,500 Australians</a> undergoing dialysis. End stage kidney disease often occurs gradually and is commonly a result of diabetes, high blood pressure and types of autoimmune kidney disease called glomerulonephritis. </p>
<p>Many patients with end stage kidney disease <a href="https://www.ncbi.nlm.nih.gov/pubmed/10580071">would live longer</a> and have a better quality of life following a kidney transplant compared to staying on dialysis. But the shortage of donor organs means preference is given to those likely to have better outcomes and reasonable life expectancy after transplantation. </p>
<p>Australian <a href="http://www.donatelife.gov.au/sites/default/files/TSANZ%20Clinical%20Guidelines%20for%20Organ%20Transplantation%20from%20Deceased%20Donors_Version%201.0_April%202016.pdf">guidelines require</a> patients have an 80% likelihood of survival at five years after transplantation to be eligible for the wait list. Tests are done to ensure the potential transplant recipient has acceptable heart health to undergo the operation, and that there are no cancers or infections that will be made worse by medications that suppress the immune system (“anti-rejection drugs”). </p>
<p>The donor’s kidney function is assessed, and the risk of them developing a kidney disease in future is evaluated. This is both to ensure the donor enjoys good kidney function after removal of their kidney, and that the recipient receives a well-functioning kidney. Donors also routinely undergo psychological evaluation.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/172673/original/file-20170607-11301-z73n3o.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/172673/original/file-20170607-11301-z73n3o.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/172673/original/file-20170607-11301-z73n3o.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/172673/original/file-20170607-11301-z73n3o.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/172673/original/file-20170607-11301-z73n3o.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/172673/original/file-20170607-11301-z73n3o.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/172673/original/file-20170607-11301-z73n3o.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/172673/original/file-20170607-11301-z73n3o.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Kidneys work by filtering out toxins from the blood and regulating a person’s fluid balance.</span>
<span class="attribution"><span class="source">from shutterstock.com</span></span>
</figcaption>
</figure>
<h2>Where do donors come from?</h2>
<p>A potential recipient is encouraged to ask friends and family if they would be willing to donate a kidney. If not, the potential recipient can go on the deceased donor list to wait for a compatible kidney.</p>
<p>People often donate organs to their blood relatives, but it’s also possible to give a kidney to someone who is not related, such as a spouse or close friend. Some people <a href="https://www.ncbi.nlm.nih.gov/pubmed/23600791">use social media</a> to solicit organ donations, and some have been successful. Specific matching sites also exist in countries such as the US, with the aim of getting healthy volunteers to altruistically donate a kidney. </p>
<p>But methods of acquiring a donor who is previously unknown to the recipient <a href="http://onlinelibrary.wiley.com/doi/10.1111/j.1600-6143.2011.03765.x/full">are controversial</a> and generally discouraged in Australia for ethical reasons. In Australia, a person could donate a kidney altruistically to someone on the waiting list. In this situation, the donor and recipient do not find out each other’s identity. </p>
<p>The Australian <a href="http://www.donatelife.gov.au/about-us/kidney-exchange-programme">paired-exchange program</a> allows greater numbers of live donor transplants to occur through paired kidney donor swaps. For example, if Jane’s potential donor John is unsuitable to give her a kidney because of matching issues, and Bob’s potential donor Barbara is unsuitable to give him a kidney, Barbara can donate a kidney to Jane, and John can donate a kidney to Bob. </p>
<p>Last year, an altruistic donation <a href="http://www.abc.net.au/news/2015-12-16/altruistic-kidney-donation-saves-seven-lives-in-one-day/7032292">kicked off a domino chain</a> of six paired-exchange donations, with the final kidney from a paired exchange donor going to a patient on the deceased donor waiting list.</p>
<p>Live donors must be over 18, but it’s preferable if they are over 30 as older age at donation minimises their chance of developing an unexpected condition that threatens their kidney health down the track. </p>
<h2>Do you need to be a ‘match’?</h2>
<p>Different people have different combinations of proteins on the surface of their cells that allow the immune system to determine what is part of the body (self) and what are foreign agents (non-self). These proteins are determined by genes called human leukocyte antigens (HLA). </p>
<p>The immune system is designed to recognise self HLA so it doesn’t target its own tissues. It is <a href="http://onlinelibrary.wiley.com/doi/10.1111/j.1399-0012.2012.01654.x/abstract;jsessionid=88CCDD1F42E1C2E3747A57660F0D7DA7.f02t04">advantageous to have high degrees</a> of HLA match (also called tissue match) between a donor and recipient, but it’s not absolutely necessary. A closer degree of HLA match means the immune system is less likely to reject the kidney.</p>
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<a href="https://images.theconversation.com/files/172675/original/file-20170607-11292-1yjg03.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/172675/original/file-20170607-11292-1yjg03.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/172675/original/file-20170607-11292-1yjg03.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/172675/original/file-20170607-11292-1yjg03.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/172675/original/file-20170607-11292-1yjg03.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/172675/original/file-20170607-11292-1yjg03.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/172675/original/file-20170607-11292-1yjg03.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/172675/original/file-20170607-11292-1yjg03.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Blood relatives are most likely to donate an organ.</span>
<span class="attribution"><span class="source">from shutterstock.com</span></span>
</figcaption>
</figure>
<p>Usually people need to be the same blood group to donate a kidney. But some living donor transplants can occur across different blood groups. These are called ABO incompatible transplantation. For this to happen, the recipient must <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5338156">undergo plasmapheresis</a> – a process in which antibodies (proteins that attack foreign invaders) are removed from their blood and they are given strong medication to suppress the immune system. </p>
<p>Only people with end stage kidney disease can be listed for deceased donor transplantation. But living donor transplants can be “pre-emptive”, taking place before the need for dialysis. </p>
<p>This has advantages, such as not having to take time away from work or study to do dialysis. People who undergo pre-emptive transplantion have a <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3384698/">lower risk of death</a> and loss of kidney transplant function compared to people who spend time on dialysis before getting a transplant.</p>
<h2>Are there risks to donors?</h2>
<p>Kidney donors usually remain in hospital for a few days after surgery, which is usually conducted as “keyhole surgery”. This involves a camera and instruments being inserted through a small incision and the kidney being pulled out through it.</p>
<p>Full recovery time is around six to eight weeks. Complications, such as bleeding or blood clots, <a href="https://www.ncbi.nlm.nih.gov/m/pubmed/20215610/">related to the operation</a> are rare. There is a very <a href="https://www.ncbi.nlm.nih.gov/m/pubmed/20215610/">small risk of death</a> around the time of the operation, estimated at 3.1 in 10,000 donors, or 0.031%. Although the patient populations differ, this is less than for other minor operations such appendicectomy (estimated in a <a href="https://www.ncbi.nlm.nih.gov/m/pubmed/27535664/">recent study</a> at 0.21%). </p>
<p>There is no long-term <a href="https://www.ncbi.nlm.nih.gov/m/pubmed/20215610/">increased risk of death</a> or heart disease. Donating a kidney is likely to cause a <a href="https://www.ncbi.nlm.nih.gov/m/pubmed/16880460/?i=5&from=/11502974/related">slight increase in blood pressure</a> over time. </p>
<p>After donation, the remaining kidney increases its capacity to filter blood, and <a href="https://www.ncbi.nlm.nih.gov/m/pubmed/11502974/">kidney function usually returns</a> to 70-80% of the previous level. This is adequate, and does not result in any symptoms related to kidney disease.</p>
<p>Studies comparing kidney donors to equivalently healthy non-donors found kidney donation <a href="https://www.ncbi.nlm.nih.gov/m/pubmed/26544982/">increases risk</a> of end stage kidney disease about three- to five-fold. But the risk is very <a href="https://www.ncbi.nlm.nih.gov/m/pubmed/26544982/">low to begin with</a> (around 0.06% for a white US man and 0.04% for a white US woman).</p>
<p>The kidney donation experience is usually positive. In one study, 95% of <a href="http://www.ajkd.org/article/S0272-6386%2812%2900003-0/abstract">kidney donors in the US</a> rated their experience as good to excellent. They reported an improvement in their sense of meaning in life and self-esteem. But a degree of psychological stress related to donation was common, and 20% reported a financial burden. </p>
<p>The Australian government <a href="http://www.immunise.health.gov.au/internet/budget/publishing.nsf/Content/budget2017-factsheet44.htm">gives A$4.1 million to run</a> the Supporting Living Organ Donors program. This scheme includes reimbursing employers for sick leave for those who donate an organ, as well as other initiatives that aim to remove financial barriers to organ donation.</p>
<hr>
<p><em>More information about living kidney donation is available at <a href="http://www.donatelife.gov.au/donor-family-support/living-donors">Donate Life</a>, <a href="http://kidney.org.au/your-kidneys/support/organ-donation/living-donors">Kidney Health Australia</a>, and the <a href="http://www.health.gov.au/internet/main/publishing.nsf/content/leave-for-living-organ-donors">Supporting Living Organ Donors program</a>.</em></p><img src="https://counter.theconversation.com/content/78041/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Holly Hutton is the recipient of an NHMRC postgraduate scholarship. (Grant number 1075304)</span></em></p>Many patients with end stage kidney disease would live longer and have a better quality of life with a kidney transplant compared to staying on dialysis.Holly Hutton, Nephrologist, PhD candidate at Centre for Inflammatory Diseases, Monash University., Monash UniversityLicensed as Creative Commons – attribution, no derivatives.